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Child Healthcare: Diarrhoea

Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin
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Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

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5 Diarrhoea 5-2 Is diarrhoea common? Objectives Yes, it is one of the commonest problems in childhood throughout the world. When you have completed this unit you should be able to: 5-3 Can diarrhoea be dangerous? • Define and diagnose diarrhoea. • Understand the importance and Yes. Diarrhoea can be life threatening if it is danger of diarrhoea. severe. Diarrhoea causes a loss of fluid and • List the causes and complications of electrolytes in the stool, which can result in diarrhoea. dehydration and electrolyte imbalance. The • Diagnose and grade the severity of correct management of diarrhoea is important dehydration. as diarrhoea is one of the leading causes of • Manage diarrhoea. death in children, especially in poor countries. • Treat dehydration. Each year about 4 million children worldwide • Prevent diarrhoea. die of diarrhoea. Diarrhoea is a leading cause of infant deathDIAGNOSIS AND CAUSES worldwide.OF DIARRHOEA 5-4 What are the common causes of diarrhoea?5-1 What is diarrhoea? The 2 commonest causes of diarrhoea are:Diarrhoea (or diarrhoeal disease) is definedas the passage of frequent, loose, watery stools 1. Gastroentestinal infectionsat least 3 times a day. Diarrhoea is not a single 2. Food allergy or intolerancecondition but simply a clinical sign, which NOTE Less common causes of diarrhoea includehas many different causes. With diarrhoea food poisoning (bacterial toxins), a side effect ofexcessive amounts of water and electrolytes antibiotics (bacterial overgrowth), some drugs(salts such as sodium and potassium) are lost which increase gut motility, coeliac disease andinto the stool. cystic fibrosis (malabsorption).

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DIARRHOEA 955-5 What infections cause diarrhoea? electrolytes into the stool. It is the commonest form of diarrhoea in childhood. Vomiting1. Infections of the bowel: and abdominal cramps in older children are • Viruses, such as Rota virus and common with gastroenteritis but pyrexia is measles. Rota virus is the commonest absent or only mild. cause of diarrhoea in children. • Bacteria, such as E. coli (Eschericia coli), Gastroenteritis is usually caused by Rota virus Shigella, Salmonella, Campylobacter or E. coli. Rota virus is highly infectious and and Cholera. seen in both poor and wealthy communities • Protozoa (small one-celled organisms), especially in children less than 1 year old. The such as Giardia, Amoeba and infection is usually spread from the stool of Cryptosporidium. the infected person by unwashed hands or2. Infections outside the bowel: contaminated water or food (the faecal–oral • Children with bacterial infections, such route). Poor hygiene or sanitation may result as otitis media, septicaemia and urinary in outbreaks of gastroenteritis. Gastroenteritis tract infection may also have diarrhoea. usually presents as acute diarrhoea. However, • In some children who present with if the bowel mucosa is damaged by the diarrhoea, the infection is not in infection, gastroenteritis may also result in the bowel but elsewhere (parenteral persistent diarrhoea. diarrhoea). Gastroenteritis is an acute infection of the bowel, Rota virus infection of the bowel is the causing diarrhoea. commonest cause of diarrhoea in children. NOTE Rota virus causes direct bowel mucosal damage while most types of E. coli produce5-6 What food intolerances cause toxins which interfere with the normal functiondiarrhoea? of the bowel wall leading to excess water and1. Carbohydrate intolerance especially lactose electrolyte loss. intolerance.2. Protein intolerance especially cow’s milk 5-8 What is acute diarrhoea? protein intolerance. Acute diarrhoea is watery diarrhoea whichBoth lactose intolerance and cow’s milk lasts less than 2 weeks (14 days). Acuteprotein intolerance usually cause persistent diarrhoea is usually due to gastroenteritis (andiarrhoea following earlier damage to the acute infection of the bowel).bowel caused by gastroenteritis. NOTE Often the term gastroenteritis and acute NOTE Diarrhoea due to carbohydrate induced diarrhoea are used interchangeably. However, intolerance may be caused by the excessive acute diarrhoea is not always caused by an intake of fruit juice especially apple juice (fructose infection of the bowel but can also result from intolerance). an infection elsewhere in the body or food intolerance.5-7 What is gastroenteritis? 5-9 What is persistent diarrhoea?Gastroenteritis (or acute diarrhoeal disease)is an acute infection of the bowel resulting Diarrhoea usually recovers within 7 days.in watery diarrhoea without visible blood However, if diarrhoea does not recover byor mucus in the stool. It is caused by a wide 2 weeks (14 days), it is called persistentrange of organisms which interfere with the (prolonged or chronic) diarrhoea. Persistentnormal functioning of the cells that line the diarrhoea is common in malnourishedbowel wall, resulting in loss of water and children and children with HIV infection.

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96 DIARRHOEA Diarrhoea for more than 14 days is persistent 5-13 What is cholera? diarrhoea. Cholera is a severe, highly infectious form of watery diarrhoea which is common in undeveloped countries. Cholera occurs in5-10 What is the relationship between epidemics as has happened in some areas ofdiarrhoea and malnutrition? South Africa in recent years. It is caused byDiarrhoea is commoner and more severe in a bowel infection with Vibrio cholerae. Thechildren with malnutrition (i.e. undernutrition). stools in cholera as typically watery with smallTherefore malnourished children often have pieces (flecks) of mucus (‘rice water stools’).persistent or repeated diarrhoea. In addition, Cholera can rapidly lead to dehydration andmalnourished children are more likely to death, even in adults. Always think of choleradevelop severe diarrhoea and die from it. if there is a local epidemic, especially withThere is therefore a close relationship between severe dehydration in an older child.diarrhoea and malnutrition. 5-14 What is dysentery? Diarrhoea is both common and more severe in Dysentery is a form of diarrhoea where the children with malnutrition. stool is not simply watery, but also contains visible blood and mucus. Dysentery is usuallyPersistent or repeated diarrhoea may result caused by organisms which invade andin weight loss and malnutrition in children damage the bowel wall. These children usuallywho were previously well nourished. look ill (toxic) and have a high temperature.Diarrhoea, especially persistent diarrhoea, Dysentery is usually caused by Shigella,often precipitates marasmus or kwashiorkor in Salmonella, Campylobacter, Amoeba andchildren who already are mildly malnourished. some types of E. coli. The commonest causeTherefore, both malnutrition and diarrhoea of dysentery is Shigella. Dysentery is severe ifoften occur in the same children. The one con- there are signs of dehydration.dition often makes the other condition worse. Dysentery is diarrhoea containing blood and Diarrhoea may precipitate or aggravate mucus. malnutrition. NOTE With dysentery, the organisms invade and damage the bowel wall, causing bleeding and5-11 Is diarrhoea common in children with the secretion of mucus.HIV infection?Yes, diarrhoea is common and may be the 5-15 What is typhoid?presenting sign in children with HIV infection. Some bacteria which cause diarrhoea, canIn children with HIV infection, diarrhoea is invade the bowel wall and spread into thenot only more frequent but also more severe blood stream resulting in septicaemia.and takes longer to recover. Diarrhoea is often Septicaemia usually complicates diarrhoeapersistent in children with HIV infection and with infections caused by Salmonella, Shigellais a common cause of death. and Campylobacter. Septicaemia is commoner in dysentery than in watery diarrhoea.5-12 Which infants are at greatest risk of Typhoid is a septicaemia caused by a boweldying from diarrhoea? infection with Salmonella typhi. These children• Infants under 6 months of age are very ill and may die if not treated early• Malnourished infants with antibiotics.• Children with AIDS

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DIARRHOEA 97 NOTE Children with typhoid may appear severely NOTE In an attempt to keep the intravascular ill and toxic with only mild diarrhoea or no volume as normal as possible, interstitial and diarrhoea at all. intracellular fluid is moved into the intravascular compartment (serum). This dehydrates the tissues resulting in loss of skin turgor, sunken eyes and aTHE COMPLICATIONS OF sunken fontanelle.ACUTE DIARRHOEA 5-18 How can you recognise loss of skin turgor?5-16 What are the complications of acute The normal skin turgor is the elasticitydiarrhoea? (stretch) which enables skin to rapidly return to its previous position after it is gently pinched• Dehydration into a tent shape for 2 seconds. Normally skin• Shock returns to its position immediately after being• Acidosis pinched and then released. With decreased• Electrolyte loss skin turgor, the skin takes longer than normal• Ileus to return to its previous position. Decreased• Hypoglycaemia skin turgor is caused by a loss of fluid from the• Septicaemia skin. The greater the loss of skin turgor, the• Malnutrition longer it takes for the skin to go back to theSevere dehydration is the commonest cause of normal position.death in infants with diarrhoea and by far the Skin turgor is best tested over the abdomen.most important complication. Using the thumb and first finger, a fold of skin on one side of the umbilicus is lifted Dehydration is the most important complication and gently squeezed for 2 seconds and then and the commonest cause of death in infants released. Observe how quickly or slowly the skin returns to its normal position. with diarrhoea. NOTE Wasted newborn infants and marasmic children may have decreased skin turgor without5-17 How can you recognise dehydration? being dehydrated (lack of subcutaneous fat)Dehydration develops when excessive amounts while decreased skin turgor can be difficult toof fluid are lost from the body. Diarrhoea detect in fat children who are dehydrated.can rapidly lead to dehydration, especiallyif vomiting is also present. Both the history 5-19 How can the degree of dehydration beand the clinical examination are important in assessed?assessing whether a child is dehydrated. All children with diarrhoea must beIn all children with diarrhoea the following examined for signs of dehydration. Thesigns must be looked for: degree of dehydration can be roughly assessed clinically into ‘no visible’ dehydration, ‘some’• Offer the child a drink. Is the child able dehydration or ‘severe’ dehydration. This is to drink? Is there increased thirst or a important as it is essential to identify children refusal to drink? Does the child vomit after with severe dehydration. drinking?• Is the child restless and irritable or 1. ‘No visible’ dehydration: The child has no lethargic or unconscious? signs of dehydration or not enough signs to• Are the eyes sunken? be classified as ‘some dehydration’. However,• Is the skin turgor (elasticity) decreased? many children with ‘no visible dehydration’• Is the infant’s fontanelle sunken? have still lost more fluid than normal. They• Has there been a sudden weight loss? often are thirsty and pass little urine.

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98 DIARRHOEA2. ‘Some’ dehydration: They have 2 or more of assessing the degree of dehydration is only the following signs: of limited use. With ‘some’ dehydration, less • Very thirsty and drinks eagerly than 10% of body weight is lost while 10% • Restless and irritable or more of body weight is lost with ‘severe’ • Sunken eyes dehydration. A child may lose up to 5% of • Moderate degree of decreased skin body weight (and body fluid) before the signs turgor. When pinched, the skin takes of dehydration can be recognized. longer than usual, but less than 2 NOTE If a child is 10% dehydrated, 10% of the seconds, to return to normal. body weight will have been lost as fluid in the3. ‘Severe’ dehydration: They have 2 or more stool or vomitus (i.e. 100 ml/kg as 1 ml of body of the following signs: fluid weighs 1 g). • Not able to drink or drinks very poorly • Lethargic or unconscious 5-21 What is shock? • Eyes very sunken. • Severe decrease in skin turgor. When Shock (hypovolaemic shock in dehydration) pinched, the skin takes 2 seconds or is the failure of the heart to maintain adequate more to return to normal. circulation due to the loss of fluid. With • Shock with delayed capillary filling time excessive fluid loss in the stools, the volume of fluid in the circulation falls and there is notSevere dehydration leads to shock, acidosis, enough fluid to allow normal blood flow to theelectrolyte loss, an ileus and hypoglycaemia. small capillaries of the body. As a result, bloodAlways start by first looking for signs of severe flow slows down or stops in the capillaries anddehydration. If the child has 2 or more signs of the body cells do not receive enough oxygensevere dehydration, then the child is classified and food. Shock presents with:as severe dehydration. If the child does not • A delayed capillary filling timehave 2 or more signs of severe dehydration, • Tachycardia (a fast heart rate)then look for signs of some dehydration. If • A weak radial pulse which is difficult to feelthere are 2 or more signs of some dehydration, • Hypothermia (low body temperature)the child is classified as some dehydration. especially cold hands and feet (coldIf there are no signs or only 1 sign of some peripheries)dehydration present the child is classified as • A depressed level of consciousnessno visible dehydration. (lethargy and drowsiness) • Hypotension (low blood pressure) with The degree of dehydration must always be weak or impalpable peripheral pulses assessed in children with diarrhoea. The blood pressure may still be normal in the early stages of shock. Shock is a very serious NOTE Children with ‘some’ dehydration often also sign and indicates that the child will probably have a dry mouth, poor urine output and do die unless immediate treatment is started. not look well. Children with ‘severe’ dehydration appear severely ill and are hypotensive, with a rapid, weak pulse, cold peripheries, and have Shock is the failure of the peripheral circulation acidotic breathing. due to the loss of fluid.5-20 How can weight loss help to decide 5-22 How is a delayed capillary filling timethe degree of dehydration? measured?Weight loss is the best measure of the degree The most important sign of shock is a delayedof dehydration. Unfortunately the child’s capillary filling time of more than 3 seconds.weight at the onset of the diarrhoea is The capillary filling time is measured byoften not known. Therefore, this method of

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DIARRHOEA 99pressing on the sole of the child’s foot or palm calcium, magnesium, chloride, phosphate,andof the hand, then releasing the pressure and bicarbonate. Electrolytes are also lost withcounting how many seconds it takes for the excessive vomiting.pale area to regain its pink colour. Pressing onthe nail of the middle finger can also be usedto measure the capillary filling time. In order Children with diarrhoea lose excessive amountsto count in seconds, and not too fast or too of fluid and electrolytes in the stool.slow, it is useful to count ‘one crocodile, twocrocodiles, three crocodiles, etc’. The return of An electrolyte imbalance (too much or toocolour to the pale area is due to the capillaries little of one or more of the electrolytes) may befilling once more with blood. Therefore, this is a caused by dehydration or using an incorrect re-good way of assessing the state of the peripheral hydration fluid. Electrolyte imbalance presentscirculation (the blood flow through the as floppiness (hypotonia), drowsiness or fits.capillaries). Slow filling of the capillaries shows NOTE Children who lose more water than sodiumthat the blood is not circulating properly. develop hypertonic (hypernatraemic) dehydration. These children are very irritable and may have convulsions. The diagnosis may be missed as the A delay in the capillary filling time is the best way signs of dehydration are less obvious. of diagnosing shock. 5-25 What is ileus?5-23 What causes acidosis in children with Ileus is distension of the abdomen due to adiarrhoea? decrease or absence of the bowel movementsWith poor peripheral perfusion due to shock, (peristalsis). No bowel sounds can be heard.many cells in the body no longer receive This lack of peristalsis is due to infection andenough oxygen and, therefore, are no longer loss of potassium. Ileus usually does not causeable to produce energy by fully breaking abdominal pain or bile stained vomiting.down carbohydrates and fats. This failureof metabolism results in the formation and 5-26 What is the danger of hypoglycaemia?accumulation of lactic acid, which causes Hypoglycaemia in children is defined as a bloodmetabolic acidosis. Metabolic acidosis is made glucose concentration of less than 3 mmol/l.worse in diarrhoea by the loss of bicarbonate Severe diarrhoea, especially in malnourishedin the stool. The use of aspirin (salicylates) children who refuse feeds or have severemay also make the acidosis worse. vomiting, may cause hypoglycaemia. This canChildren with a metabolic acidosis develop result in loss of consciousness or convulsions.rapid sighing (deep) breathing. The clinical Hypoglycaemia must always be suspected indiagnosis of acidosis can be confirmed by children with diarrhoea who have fits or ablood gas analysis. decreased level of consciousness. NOTE The blood gas analysis in an infant with a Hypoglycaemia is a very serious complication metabolic acidosis shows a low pH and low stan- that requires urgent diagnosis and immediate dard bicarbonate together with an increased base treatment with intravenous glucose. Hypo- deficit. In an attempt to correct the acidosis, the child often hyperventilates which lowers the pCO2. glycaemia can be confirmed by measuring the blood glucose concentration with a reagent strip.5-24 Why do children with diarrhoea loseelectrolytes? 5-27 How is septicaemia recognised?Children with diarrhoea lose both fluid andelectrolytes in the stool. Important electrolytes Some infants with diarrhoea appear very illwhich are lost include sodium, potassium, and have bacteria circulating in their blood.

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100 DIARRHOEAThis is called septicaemia. Septicaemia Treatment must be started early and everyshould be suspected if the child has a high effort must be made to prevent dehydrationtemperature (pyrexia) or appears a lot sicker by replacing the fluid losses. It is importantthat you would expect for the degree of to teach mothers that acute diarrhoea isdehydration or does not improve after the treated with oral rehydration solution and notdehydration is corrected. Septicaemia is with medicines. Thirst is often a good guidecommoner in infants below 3 months, in to the need for oral rehydration solution.malnourished children and in children with The management of most children withdysentery. Associated HIV infection makes acute diarrhoea is both simple and cheap.septicaemia more likely, more serious and Intravenous fluid (‘a drip’) is usually notmore dangerous. necessary. There is no need for routine stool cultures in acute diarrhoea.5-28 What signs suggest that the diarrhoeamay have a surgical cause? The early use of oral rehydration solution can• Repeated, severe vomiting usually prevent dehydration.• A markedly distended abdomen• Bile stained vomiting 5-30 Will milk feeds make acute diarrhoea• Passing a lot of blood and mucus with little worse? stool• Severe, continuing abdominal pain (not Although continuing milk feeds in infants just intermittent cramping pains) may appear to make the diarrhoea worse, it is important to continue feeds as it helps toThese children must be referred to hospital provide energy and replace fluid and electrolyteurgently for further investigation. losses. Infants recover from diarrhoea faster if milk feeds are continued. Breastfeeding or full- strength formula should be used. There is noTREATMENT OF need to dilute feeds. The aim of feeding duringDIARRHOEA diarrhoea is to maintain nutrition. Rehydration solution should be given in addition and not be used to replace feeds.5-29 What is the management of a childwith acute diarrhoea? Milk feeds must not be stopped in infants with1. The most important aspect of management acute diarrhoea. is to start oral rehydration therapy as early as possible to prevent dehydration 5-31 Can children with acute diarrhoea from occurring. Oral rehydration solution continue to be fed solid food? should be used. With frequent, small drinks most children with mild diarrhoea If the child is already receiving solid food, can be adequately managed without this should be continued unless the child is developing dehydration. vomiting a lot. Small feeds should be given2. Breastfeeding, formula or solid feeds frequently (at least every 4 hours). This is should be continued unless the child has particularly important in children who are severe vomiting. malnourished as diarrhoea can make the3. The clinical condition of the child must malnutrition rapidly worse. Extra feeds should be continually assessed for signs of be given while the child is recovering from complications, especially dehydration. the diarrhoea to improve weight gain. Feeding4. Treat the complications if they occur. during diarrhoea does not increase the number of stools.

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DIARRHOEA 1015-32 Should anti-diarrhoeal medication be rehydration solution is vomited, a smallerused to treat acute diarrhoea? amount should be given slowly about 10 minutes later. The best way to avoid vomitingMedicine is usually not necessary and may is to give small sips of fluid frequently by cup.even be dangerous in small children. Anti- If severe vomiting continues, a serious causediarrhoeal medication such as codeine, of the diarrhoea should be looked for, andImodium (loperamide) and Lomotil continuous nasograstric or intravenous fluid(diphenoxylate) decrease peristalsis and may must be started.cause ileus. They improve cramps in olderchildren but do not prevent the loss of fluid There is no role for antiemetics (drugs whichand electrolytes from the gut. Medications stop vomiting) in the management of vomitingwhich absorb water like pectin and kaolin have in children with acute diarrhoea. They canno role in the management of children with have serious side effects.diarrhoea. Antiemetics (to reduce vomiting)are also not used. Traditional medicine, 5-35 Can a child with acute diarrhoea beespecially enemas, must not be given. treated at home? Children with mild diarrhoea and no visible5-33 Should antibiotics be routinely given signs of dehydration can be treated at hometo children with acute diarrhoea? with continuing feeds and oral rehydrationMost cases of acute diarrhoea are caused by solution. If the diarrhoea becomes worse ora virus and do not respond to antibiotics. does not recover in 2 days the child must beIndication for antibiotics are: seen at a clinic. Children who refuse to drink or who vomit repeatedly must be taken to a• Suspected septicaemia (very ill with a high clinic immediately as they are at great risk of fever) dehydration. Counsel the mother to seek help• Small infants (under 1 month) if the infant’s eyes or fontanelle appear sunken.• Severely malnourished children Most children with diarrhoea can be managed• Dysentery (blood in the stools) at home. The mother must know how to give• Suspected cholera rehydration solution correctly and when toInfants who are sick enough to receive bring the child back to clinic.antibiotics should be referred to hospital formanagement. Children with mild diarrhoea can be treated at home with feeds and oral rehydration solution. Routine antibiotics should not be used to treat acute diarrhoea. The guidelines for managing acute diarrhoea at home are: NOTE Ill infants with suspected septicaemia must receive systemic antibiotics. Dysentery (often due 1. Give extra fluids. to Shigella) is usually treated with oral nalidixic 2. Continue feeding. acid (12.5 mg/kg/dose 6 hourly for 5 days) while 3. Know when to take the child to the clinic persistent diarrhoea (often due to Amoebae or or hospital. Giardia) is treated with metronidazole (Flagyl). 5-36 What is oral rehydration therapy?5-34 What should you do if the child vomits Oral rehydration therapy (ORT) is the mosta lot? important part of managing acute diarrhoeaInfants with acute diarrhoea may vomit. and saves the lives of millions of childrenHowever, the vomiting usually stops once worldwide each year. ORT consists of givingthe dehydration is corrected. If the oral oral rehydration solution by mouth early in

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102 DIARRHOEAacute diarrhoea to prevent or treat dehydration. 1. 1 litre of clean water.Give frequent small sips from a cup. 2. 8 level teaspoons of sugar. 3. ½ of a level teaspoon of table salt. Oral rehydration therapy saves million of lives One litre of water can be measured with a every year. measuring jug or a one litre cool drink bottle. The sugar and salt must be added to the litre of clean water and mixed well. It is very important5-37 What is oral rehydration solution? not to add too much salt. If possible, the sugarOral rehydration solution (ORS) is a mixture and salt solution should be given by cup orof water, electrolytes (salts) and glucose which by spoon as this avoids using dirty bottles. Itis given by mouth to provide energy and is dangerous to add a sachet of rehydrationreplace the fluid and electrolytes which have powder to the sugar and salt solution as this willbeen lost. Oral rehydration solution can be: make the solution too concentrated.• Bought commercially.• Made up in the home as a sugar and salt A sugar and salt solution for oral rehydration can solution. be easily made up at home.5-38 What is commercial oral rehydration 5-40 Who should know how to make upsolution? sugar and salt solution for oral rehydration?There are a number of different brands of Every mother or caretaker should know howcommercially available oral rehydration to make up a sugar and salt solution and havesolution (e.g. Sorol). They all contain a the necessary ingredients at home. The recipebalanced mixture of electrolytes and water for making sugar and salt solution is given intogether with glucose. They are usually sold some Road-to-Health Cards.in the form of a powder which is packaged ina sachet (small packet). One sachet of powder 5-41 When should oral rehydration therapyshould be mixed in one litre of water. The be started?cleanest available water must be used. Sterileor boiled water (which has been allowed to As soon as the diarrhoea is noticed. It is verycool) is best. Commercial oral rehydration important to start oral rehydration therapysolution powder should be kept in as many as early as possible to prevent dehydration.homes with children as possible. The earlier it is started the quicker the child NOTE Standard ORS contains 90 mmol/l of sodium will get better. It is important to start oral and 111 mmol/l of glucose. However, WHO and rehydration therapy before taking the child to UNICEF have recently advised that a solution a doctor or nurse. of 75 mmol/l of both sodium and glucose is preferable as it gives an effective ORS with a lower osmolality. Oral rehydration therapy at home should be started as soon as possible, to prevent dehydration.5-39 How can a sugar and salt solution bemade at home? 5-42 How much oral rehydration solution should be given?Home made sugar and salt solution (SSS)is not quite as good as commercial oral It is best to give the oral rehydration solutionrehydration solution as it does not contain frequently and in small volumes. Too muchpotassium. However, it is immediately fluid at one time may cause vomiting. Giveavailable and often lifesaving.. The commonest as much fluid as the child will take. Mostrecipe for a sugar and salt solution is: children with no or only some dehydration

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DIARRHOEA 103will drink as much oral rehdration fluid as 5-45 What is the management ofthey need to replace the fluid lost. Children dysentery?with some dehydration are usually very thirsty. These children should be referred to hospitalHowever, children with severe dehydration are for investigation and treatment. Correctvery ill and may refuse to drink. Usually 25 ml dehydration. An antibiotic is needed. Usually,(5 teaspoons) can be given every 10 minutes. nalidixic acid is given 6 hourly for 5 days (2.5If the child vomits, try again in another 10 ml if 12 to 24 months; 5 ml if 2 to 5 years; 7.5minutes. If the child refuses the fluid or ml if older than 5 years).continues to vomit the fluid, nasogastric orintravenous therapy may be needed. This is NOTE Dysentry is usually due to Shigella, whichparticularly important if a vomiting child has become resistant over the years to manyappears to be dehydrated. antibiotics. Ciprofloxacin may be required.5-43 Which children with acute diarrhoeashould be referred to hospital? MANAGEMENT OFMost children with acute diarrhoea can be DEHYDRATIONmanaged at home or at a primary care clinic.However, the following children should be 5-46 What is the management of a childreferred to hospital for further management: with diarrhoea but no visible dehydration?• Children with signs of severe dehydration These children are losing excessive amounts or shock of fluid and electrolytes in their stools and• Children who have lost more than 10% of therefore must still be given extra fluid and their body weight electrolytes to prevent signs of dehydration• Children who continue to vomit despite from appearing. being given oral rehydration solution• Children with a fever or other signs of 1. These children should be managed at infection home or at a clinic using commercial oral• Children who have had a convulsion (fit) rehydration solution or sugar and salt or are very irritable solution to replace fluid losses. Give as much fluid as the child will take. Continue5-44 What is the management of persistent with extra fluids until the diarrhoea stops.diarrhoea? 2. Normal feeds should be continued. breastfeeding mothers should continue toChildren with persistent diarrhoea should give breastfeeds.be referred to hospital for investigation and 3. The child should be closely observed forfurther management. Correct dehydration if continuing loose stools or vomiting. Signspresent. Offer oral rehydration solution even of dehydration must also be looked for.if the child is not visibly dehydrated. Consider 4. The mother should bring the child to theHIV in any child with persistent diarrhoea. clinic immediately if the child becomes NOTE The stool should be cultured and examined more sick, develops signs of dehydration, under a microscope in an attempt to identify the refuses feeds or vomits a lot. cause. Secondary lactose intolerance is common. 5. Children with diarrhoea but no visible Often a lactose free formula (Isomil, Infasoy) is dehydration, who are managed at home, given for a few weeks. should return to the clinic in 5 days if the diarrhoea has not stopped. The aim of early home care is to prevent dehydration and continue feeding. The mother must know what fluids to use and how much

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104 DIARRHOEAto give. She must also know when to return to plus oral rehydration solution until thethe clinic. diarrhoea stops. Oral rehydration solution does not cause the fluid loss in the stools to increase. Home care with oral rehydration solution can 6. The mother must know how to make up usually prevent dehydration. the rehydration solution correctly and how much to give. NOTE Children with ‘no visible’ dehydration who do not meet the criteria needed to be classified If the infant refuses to drink fluids or vomits as ‘some’ dehydration may still have lost about 5% repeatedly after drinking, a continuous of their body fluid (about 5% loss in body weight nasogastric drip should be started. If there and therefore need extra fluids). are still signs of ‘some’ dehydration after 4 hours, continue with the oral or nasogastric5-47 What is the treatment of a child with rehydration solution and assess again after asome dehydration? further 4 hours. If signs of severe dehydration develop, manage the child for ‘severe’These children with 2 or more clinical signs dehydration.of ‘some’ dehydration should initially bemanaged in a clinic or hospital if possible as The lives of most children with diarrhoeathey can progress to ‘severe’ dehydration: can be saved by the simple, cheap use of oral rehydration therapy at home or in a local1. They can be treated with oral rehydration primary care clinic. solution with a close watch for repeated vomiting or a refusal to drink. It is best if the oral rehydation solution is given by Children with some dehydration are treated at a cup and/or spoon. clinic or hospital with extra fluids in addition to2. 80 ml/kg of oral rehydration solution continuing normal feeds. should be given over 4 hours, i.e. about 20 ml/kg each hour. More can be given if the NOTE The WHO recommends 75 ml/kg of oral child wants to drink more. It is best if the rehydration solution over 4 hours. child has frequent, small sips. If the child vomits, wait for 10 minutes and then try 5-48 What is the treatment of a child with again more slowly. severe dehydration?3. The degree of dehydration must be assessed after 4 hours. The management of children with severe4. If the child takes the oral rehydration diarrhoea leading to severe dehydration is a solution well, is not vomiting and there are medical emergency. Look carefully for shock no longer signs of dehydration (and the in all children with severe dehydration and child has gained weight) after 4 hours, the treat immediately. child can be sent home and return to be 1. Immediately start an intravenous infusion assessed the next day. At home the child with Ringer’s lactate (or half normal saline should be managed with oral rehydration or half strength Darrows/dextrose solution). solution (as for diarrhoea with ‘no visible’ 2. Give 30 ml/kg over the first half hour (30 dehydration). The decision to send the minutes). Then give 70 ml/kg over 2 ½ child home will depend on the home hours (i.e. about 30 ml/kg per hour). Most circumstances. The mother must bring the infants are therefore rehydrated with 100 child back immediately if the diarrhoea ml/kg over 3 hours. gets worse, the child vomits everything or 3. The child must be closely observed and signs of dehydration appear. reassessed every half hour. If the clinical5. It is important that the child continues to signs of dehydration have not improved receive regular feeds (especially breastfeeds) after an hour, fluid should be given faster.

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DIARRHOEA 105 Careful assessment after 3 hours is needed 5-49 What is the treatment of dehydration to decide whether further management resulting in shock? should be for ‘no visible’, ‘some’ or ‘severe’ Give intravenous Ringer’s lactate or normal dehydration. saline 20 ml/kg as fast as possible. Continue to4. If an intravenous infusion cannot be give fluid at this fast rate until the signs of shock started, pass a nasogastric tube and give have disappeared. An easily felt radial pulse and 20 ml/kg/hour over 6 hours (i.e. 120 ml/ normal capillary filling time are very reassuring kg). Nasogastric rehydration is slower than signs of a good response to management. Once intravenous rehydration as it takes time for shock has been corrected, Ringer’s lactate, the fluid to be absorbed. If there is repeated half normal saline or half Darrows/dextrose vomiting or abdominal distension, give solution is then given at the standard rate for the nasogastric fluid slower or try again to severe dehydration (i.e. 30 ml/kg per hour). start an intravenous infusion.5. Only once intravenous or nasogastric rehydration has been started, should 20 ml/kg of intravenous fluid is given as fast as the child be moved urgently to hospital. possible if shock is present. Always start replacing fluid before moving the child. One of the commonest mistakes If it is not possible to start an intravenous line, made is to rush the child to hospital before the intraosseous route can be used in young starting intravenous or nasogastric fluid. If children if the health worker is trained in this no equipment is available to give fluid fast, technique. A nasogastric drip can be used if try to get the child to drink while being neither intravenous or intraosseous routes urgently transported to hospital. are available. Haemacel, fresh frozen plasma6. Oral rehydration solution should be started or stabilized human serum (SHS) can also be when the child is able to drink. used to treat shock. Using the intraosseousNever rehydrate an infant or child with 5% or route in children under six years of age can be10% dextrose only as they need electrolytes as a life-saving procedure.well as fluid and glucose. Rehydration fluidsmust always contain some glucose (dextrose). In an emergency with ongoing shock, where several attempts to place an intravenous line have failed, use the intraosseous route. The Children with severe dehydration should be most suitable site is 2 cm below the tibial rehydrated with 100 ml/kg of fluid intravenously tuberosity on the flat surface of the tibia (shin over 3 hours. bone). A wide-bore needle (15–18 gauge) can be used if a needle with stylet is not available. NOTE In infants under one year it is best to give In children under 18 months, an 18 × 1.5 or 30 ml/kg for the first hour while the remaining 20 × 1.5 lumbar puncture needle is suitable. 70 ml/kg is given slower over a further five hours. Hold the needle perpendicular to the skin and Therefore, small infants are rehydrated slower with a twisting movement push it into the flat with 100 ml/kg over 6 hours. part of the tibia until a ‘give’ is felt; the needleThe amount and rate of fluid needed to correct is now in the bone marrow. Do not advance itsevere dehydration has been controversial for any further. In a shocked patient, fluid must bemany years. The Red Cross Children’s Hospital introduced under pressure (use a 20 ml syringein Cape Town, South Africa, recommends 20 m/ as a ‘push-in’ or a sphygmomanometer cuffkg over the first 30 minutes followed by 100 ml/ wrapped around a collapsible IV plastic fluidkg over the next 4 hours. This regimen avoids container). The dosage and volume of drugsthe dangers of rehydrating a child too fast. and fluid are the same as for direct IV infusion.

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106 DIARRHOEA5-50 What fluids should be given once • Where there is not a supply of clean waterdehydration has been corrected? to mix formula • When feeding bottles and teats cannot beOnce dehydration has been corrected, the total properly cleanedamount of fluid needed is normal maintenance • In communities without adequate toiletrequirements plus any ongoing fluid losses. facilitiesThe normal fluid needs of most infants are • When flies are commonabout 100 ml/kg daily. If possible this fluid • When personal hygiene is poor, especiallyshould be given orally as rehydration solution no handwashing before eatingor milk. Thirst is usually a good guide to theinfant’s fluid needs. Diarrhoea is usually due to contaminated food or5-51 What is the value of zinc supplements water.in managing a child with diarrhoea? NOTE Faeces left on the open ground or washedZinc is an important trace element which can into the water supply by rain, pit toilets thatspeed up the recovery from diarrhoea and help overflow, and vegetables ‘freshened’ withto prevent further diarrhoea. Once the child contaminated water are all common sources ofis taking feeds well, one tablet of zinc (20 mg) infection. Infected food (e.g. eggs and shellfish)should be given daily for 10 days. Children can also result in diarrhoea.under 6 months should have half a tablet daily. 5-54 How can the risk of diarrhoea be reduced?PREVENTION OF Diarrhoea is far less common with:DIARRHOEA • Breastfeeding to 6 months and longer if possible5-52 Is acute diarrhoea preventable? • A supply of clean water • Adequate sanitation (the safe disposal ofYes. The viruses and bacteria that usually cause faeces)acute diarrhoea spead easily from person • Cup-feeding rather than bottle-feeding ifto person. Acute diarrhoea is an infectious formula is useddisease. With simple interventions, most cases • Good personal hygiene, especially hand-of acute diarrhoea can be prevented. washing before meals or handling food • Protecting food from flies Acute diarrhoea is usually very infectious but can Breastfeeding, a clean safe water supply, be prevented. appropriate hand-washing and good sanitation will prevent most cases of diarrhoea. Well5-53 Why do children commonly get nourished children are less likely to get severediarrhoea? diarrhoea than malnourished children. Breast milk contains many substances (antibodiesBecause they are exposed to the viruses and and immune cells) which protect the gut frombacteria which cause diarrhoea. Their food infection and it thereby protects the infantand water may also be contaminated by these from diarrhoea caused by infection.organisms. Infections which cause diarrhoeaare particularly common: Breastfeeding is an important way of preventing• In infants who are bottle-fed rather than diarrhoea in young infants. breastfed

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DIARRHOEA 107 NOTE Recent research shows that probiotics, such should be placed in the second smaller hole as bifidobacteria, added to formula feeds can which is at one end of the slab. The top of reduce the risk of gastroenteritis. the ventilation pipe must be covered with a fly screen. The door of the toilet should5-55 How can a safe water supply be face into the wind. The outhouse should beobtained? dark inside with no cover over the seat. Air1. Chlorinated tap water must be provided flow in the pit is down the large hole and up where ever possible. the small hole. Smell and flies escape up the2. Water can be sterilized by boiling or pipe where the flies are trapped. adding chlorine tablets.3. If none of the above is available, water can Effective, cheap sanitation can be provided with a be made safer by putting it into a clear, pit or VIP toilet. plastic bottle or bag and leaving it in the sun for a few hours. The ultraviolet light will kill Where affordable, a chemical or flush toilet most viruses or bacteria in the water. should be used. If no toilet is available, allIf the water is cloudy or dirty it should be stools must be buried immediately.filtered or be allowed to stand until the clearwater at the top can be gently poured off. The 5-57 Why is cup-feeding safer than bottle-clear water must then be sterilized. feeding? NOTE A simple water filter can be made in a If a mother is unable to safely clean dirty bottles container with holes in the bottom. At the base and teats, it is better to feed the infant by cup. of the container place a few centimetres of small Unlike a bottle, a cup can easily be cleaned with pebbles. Cover these with a few centimetres of sand (not clay). Place the container on top of a soap and water. The inside surfaces of a cup are second container in order to catch the drops of smooth and easily reached by finger. Unlike a filtered water. The dirty water can now be poured feeding bottle, there are no corners for milk and into the top container to filter down into the bacteria to lodge in. second container. Cup-feeding is safer than bottle-feeding.5-56 How can sanitation be improved?There are a number of simple ways to improve 5-58 How can hygiene be improved?sanitation and reduce the risk of childrengetting diarrhoea. All stools must be passed or • Wash hands after going to the toilet ordeposited into a flush, chemical or pit toilet: handling a soiled nappy. • Wash hands before preparing food or• A simple pit toilet: The pit must be dug less eating. than a metre wide and at least 1 to 2 metres • Wash fruit and vegetables with clean water. deep, 20 metres or more away from houses • Cover food to keep flies away. or water sources. The deeper the pit the • Store food in a fridge (refrigerator) or cool better. The pit must be covered with a slab place. or platform, having a single round hole • Bury or burn all food waste. which must be covered with a lid to keep out flies and keep in the smell. Throwing in lime, ash or soil after each use will help CASE STUDY 1 control flies and smell.• A Ventilated Improved Toilet (VIP Toilet): A mother brings her 9 month old child to a The pit should be covered by a slab with two local clinic. The child has had loose stools for holes. An outhouse should be built over the 2 days. The mother has stopped bottle feeds larger, central hole while a ventilation pipe of formula and given sugar and salt solution

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108 DIARRHOEAas advised by a general practitioner. Oral if the diarrhoea becomes worse or the child’santibiotics and an anti-diarrhoea medication general condition deteriorates. The childwere started. On examination the child has should be observed for continuing loose stoolsno signs of dehydration. Other than the loose, or vomiting. The aim of early home care is towatery stools, the child appears healthy. The prevent dehydration and continue feeding. Theolder sibling had loose stools the week before. mother must know what fluids to use and how much to give. She must also know when to1. What is the diagnosis? return to the clinic.The child has acute diarrhoea with no visibledehydration. The diarrhoea is probably dueto a bowel infection with Rota virus. The CASE STUDY 2infection probably spread from the sibling. An ill 9 month old child with diarrhoea and signs of severe dehydration is brought to a2. What could have been done to prevent local hospital. He is shocked and breathingthe diarrhoea? fast. The mother says he has had watery stoolsGood hygiene with hand-washing after going all day and vomits all feeds. The family live into the toilet and before meals. Breastfeeding a poor area with no formal toilets. Drinkingrather than formula feeds also reduces the risk water is collected from a stream. Whenof diarrhoea. Formula feeds are best given by compared to the weight recorded in the child’scup rather than bottle. Road-to-Health Card two weeks before, 15% body weight has been lost.3. Do you agree with the use of a sugar andsalt solution? 1. What are the signs of severe dehydation?Yes. Oral rehydration solution or a home • The child is not able to drink or drinksmade sugar and salt solution is the correct very poorly.management of diarrhoea. • The child is lethargic or unconscious. • The eyes are very sunken.4. Should feeds be stopped when children • There is decrease in skin turgor. Whenhave diarrhoea? pinched, the skin takes two seconds or more to return to normal.No. It is very important that feeds are • The child is shocked.continued. Stopping feeds does not improvethe diarrhoea and may lead to malnutrition. If 2 or more of these signs are positive, a diagnosis of severe dehydration is made. The5. Would you have prescribed an antibiotic? weight loss of more than 10% also suggests severe dehydration.There is no need for an antibiotic in acutediarrhoea unless the diarrhoea is caused by an 2. What are the signs of shock?infection outside the bowel, such as an acuteotitis media (ear infection). Neither is there • A delayed capillary filling timean indication for anti-diarrhoeal or antiemetic • Tachycardia (a fast heart rate)medications. • Hypothermia (low body temperature) especially cold hands and feet (cold6. Does this child need to be kept at the peripheries)clinic or admitted to hospital? • A depressed level of consciousness (lethargy and drowsiness)No. A child with no visible dehydration can • Hypotension (low blood pressure) withbe managed at home. The child should be weak or absent peripheral pulsesbrought back to the clinic in 5 days, or sooner

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DIARRHOEA 1093. Why is this child breathing fast? CASE STUDY 3He is probably acidotic. However, he may alsohave pneumonia. A child of 2 years has a one-month history of loose stools. The child has some dehydration.4. How should shock due to dehydration be The weight falls below the third centile. Ittreated? is noticed that the child has generalised lymphadenopathy. The grandmother says thatIt is very important that the child is given the child’s mother died a few months before.intravenous fluid immediately and fast. UsuallyRinger’s lactate or half Darrows/dextrose is 1. What is your diagnosis?used, starting with 20 ml/kg. The signs ofshock must be carefully observed. If the child This child has persistent diarrhoea as the looseis still shocked after the first 20 ml/kg, repeat stools have been present for more than 14 days.this amount fast. If it is not possible to startan intravenous infusion, the fluid should be 2. How is ‘some’ dehydration recognized?given via an intraosseous route or a nasogastrictube if this is not possible. The child should be The child does not have severe dehydrationtransferred immediately to hospital. but 2 or more of the following signs: • Very thirsty and drinks eagerly5. How is severe dehydration corrected? • Restless and irritable • Sunken eyesOnce the shock is corrected, the child should • Moderate degree of decreased skin turgorreceive Ringer’s lactate or Darrows/ dextrose When pinched, the skin takes longer thanintravenously (or via a nasogastric tube) to usual, but less than two seconds, to returntreat the severe dehydration. Usually 30 ml/kg to normal.is given over 30 minutes followed by 70 ml/kgover 2 ½ hours. Start oral rehydration solutiononce the child is fully conscious and able to 3. What is the correct treatment of ‘some’take fluids. dehydration? These children should be treated at a clinic or6. Why does this child have diarrhoea? in hospital. Usually oral rehydration solution is given with a close watch for repeated vomitingProbably because there are no toilets or or a refusal to drink. It is best if the oralclean drinking water. If clean tap water is not rehydration solution is given by cup. 80 ml/kgavailable, water can be sterilized by boiling or of oral rehydration solution should be givenadding chlorine tablets. If this cannot be done, over 4 hours, i.e. about 20 ml/kg each hour.water can be made safer by putting it into a More can be given if the child wants to drinkclear, plastic bottle or bag and leaving it in the more. Usually the fluid is given by cup orsun for a few hours. The ultraviolet light will spoon. It is best if the child has frequent, smallkill most viruses or bacteria in the water. sips. If the child vomits, wait for 10 minutes and then try again more slowly. The degree of7. What can be done if no toilet is available? dehydration must be assessed after 4 hours.A simple pit toilet can be made. A VentilatedImproved Toilet (VIP Toilet) would be even 4. When can this child be sent home?better. Some plan must always be made to get Children with acute diarrhoea and ‘some’rid of waste safely. dehydration can be sent home if they take the oral rehydration solution well, are not vomiting and there are no signs of dehydration after 4 hours. It is important that the child

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110 DIARRHOEAcontinues to receive regular feeds. The decision 3. How should this child be managed?to send the child home will depend on the Children with dysentery should be referredhome circumstances. The child must continue to hospital for investigation and treatment.to be offered rehydration solution frequently An antibiotic, usually nalidixic acid, is given 6and return to be assessed the next day. The hourly (7.5 ml as the child is older than 5 years).mother must bring the child back immediately Oral redydration solution should be given.if the diarrhoea gets worse, the childvomits everything or signs of dehydrationappear. However, as this child has persistent 4. What simple steps can reduce the risk ofdiarrhoea, she must be admitted to hospital for diarrhoea and dysentery?investigation and further management. Making sure that there is: • Breastfeeding to 6 months and longer if5. What is the relationship between possiblediarrhoea and malnutrition? • A supply of clean waterDiarrhoea, especially persistent diarrhoea, • Adequate sanitation (the safe disposal ofcan lead to malnutrition while children with faeces)malnutrition are at high risk of getting severe • Cup-feeding rather than bottle-feeding ifdiarrhoea. Therefore, the one often leads to formula is usedthe other. • Good personal hygiene, especially hand- washing before meals or handling food6. What illness must be suspected in thischild? 5. How can a safe water supply be obtained?AIDS. HIV infection often presents clinicallywith persistent or recurrent diarrhoea. The • Chlorinated tap water must be providedgeneralized lymphadenopathy suggests HIV wherever possible.infection. This child’s mother may have died • Water can be sterilized by boiling orof AIDS. adding chlorine tablets. • If these are not available,water can be made safer by putting it into a clear,CASE STUDY 4 plastic bottle or bag and leaving it in the sun for a few hours.An 8-year-old child presents with a week’shistory of loose stools containing both blood 6. What trace element may help theand mucus. The child has a temperature and recovery from diarrhoea?looks ill. There are no signs of dehydration. Zinc. One dissolved tablet should be taken daily for 10 days.1. What is the importance of blood in thischild’s stool?It indicates that he has dysentery.2. What may the cause be?As the child is ill with a temperature, typhoid(Salmonella) or Shigella or amoebic dysentrymust be suspected. The commonest cause ofdysentery is Shigella.